“It felt great when I saw myself”: Our Health Matters Report on Gender-Affirming Health Care for Transmasculine People

Authors: Heather Santos, Venkatesan Chakrapani, Madhusudana Battala, Shaman Gupta, Aditya Batavia, Ayden Scheim

This report is available for download in English, Hindi, and Marathi.

Our Health Matters

Our Health Matters is a community-based participatory research study of trans men’s and transmasculine people’s health in India. The study uses qualitative (in-depth interviews) and quantitative (survey) methods to explore and bring attention to transmasculine people’s experiences in society and how they impact health and well-being. This report focuses on data from the qualitative phase of the research.

The project is led by a Steering Committee of transmasculine community members and a team of trans and non-trans researchers from Drexel University (Philadelphia, USA), the Population Council (New Delhi), and other organizations in India, Canada, and the USA. Project partners include TWEET Foundation and Transmen Collective. Click here for more information about the study team.

Background

Many transgender and non-binary people need gender-affirming (or transition-related) care, including hormone therapy and surgery. Access to gender-affirming care has been associated with improved mental health among trans and non-binary individuals, such as reduced depression and anxiety. Studies also indicate that hormone therapy can positively impact quality of life. However, trans and non-binary people face many barriers to such care, including limited information, costs and lack of
insurance coverage, discrimination from medical staff, and a lack of doctors who are knowledgeable about gender-affirming care.

Despite legal recognition of trans people’s rights to gender self-identification and health care in India, the community continues to face barriers to gender-affirming and general health care. A recent review of 67 studies on access to health care for trans people in India identified common barriers including stigma and discrimination, limited access to free or low-cost care, and lack of treatment protocols. None of the studies focused on health care for the transmasculine community. More broadly, a review conducted by members of our team found limited published research on transmasculine people’s health in India and globally. To help fill this gap, this report focuses on experiences accessing gender-affirming care among trans men and transmasculine people in India.

Whom did we speak to?

We spoke to 40 transmasculine people who ranged in age from 20-50 (average = 28) and lived in 10 states in India. Participants self-identified with varied caste, religious, and socio-economic backgrounds.

How did we collect and analyze our data?

Forty in-depth interviews were conducted in Hindi or Marathi by peer researchers (trans men) via telephone or video conference in July and August 2021. The interviews were audio-recorded, transcribed, and then translated. A semi-structured interview guide was used. It focused on family experiences, social and community support, experiences of discrimination and safety, and access to health care. The questions about health care focused primarily on transition-related care. The interview transcripts were analyzed by four team members with previous experience in conducting qualitative data analysis, with the involvement of Steering Committee members.

What did we find?

Overview

The experience of trans men and transmasculine participants trying to access gender-affirming care usually began with a search for potential doctors, largely through their peers. They then had to weigh the affordability and quality of the limited number of available services, and navigate the approval process for gender-affirming care, which usually involved seeking a letter or two from a psychiatrist or psychologist. Along the way, participants had a range of both negative and positive experiences with
doctors, nurses, pharmacists, and other health care providers. Finally, despite these challenges, participants who had achieved their transition-related goals described positive impacts on their health and well-being.

Finding Information

Participants generally found information about transition-related care from transmasculine peers who they knew online or offline (often introduced through support groups). Older participants noted that younger community members would come to them for transition-related information, as they had more experience with accessing transition care. 

Some participants conducted internet searches to identify potential trans-friendly doctors and gender-affirming procedures. This was common across age groups; however, participants who began their transitions earlier noted that information was less readily available when they first needed it.  

Reliance on word-of-mouth and the internet introduced challenges for participants who needed to determine whether a source was authentic and reliable, since no official medical sources or databases were available.  

“There is one friend on Facebook who is a trans man. He told me about this. He started the process in Mumbai but did the surgery in Thailand. He said that he helped with GID. I got to know that GID can happen in [hospital name].” (26, Kalyan) 

“I met a lot of [trans] people on social media. They would suggest to me to go to this doctor and go to that doctor.” (28, Mumbai) 

“Once, I searched about sex-changing surgery online on Google. There I got to know about [clinic name].” (30, Delhi) 

“The hardest part is that at the time of the transition, I was very young… When it was 2012 or 2014, there was not much information on Instagram or Facebook.” (23, Mumbai) 

Weighing the affordability of services

The affordability of transition-related care proved to be a barrier for many participants. Participants noted having to delay transitioning until they felt financially secure and independent.  

“In March 2019, I was unemployed, so I stopped taking injections. I didn’t want to make money from my family, so I decided to stop taking injections for a while. After 5 to 6 months, I started taking injections again.” (26, Kalyan) 

In general, gender-affirming services were scarce, particularly in government hospitals. Costs of available services were inaccessible to many, particularly in the private sector. However, participants found care in private hospitals to be higher quality, with shorter wait times.  

“I had saved money as I wanted to have surgery. But then we got to know both the government and the private sector. We decided to go into government as private was costly… We went there for four to five months to get a date for the surgery. Then we got the date. But it didn’t work there. Then I saved some money and went to a private hospital.” (36, Pune) 

Some participants sought assistance from community organizations to fund their hormone treatments, while others used hormones that their friends who had prescriptions shared with them. However, many participants described having to delay surgery until they could save enough money.  

“It cost me around 15 to 20 thousand rupees [for hormones]. [Organization name] helped me with Rs. 3,000. I have recovered 90 percent since last month.” (25, Washim) 

“The top surgery is very difficult; it comprises keyhole surgery and double incision surgery. The cost of surgery is very high, and also different doctors used to charge different fees for it. So, to get this surgery, I first need to work and then only plan further for it.” (22, Jamshedpur) 

Participants from rural areas faced difficulties finding transition-related services overall, with some resorting to traveling or relocating to more urban areas. And while affordability was a common barrier for all participants seeking services, it was a particular challenge for younger participants who did not have financial independence or a regular  income.   

Weighing the quality of services

Participants experienced a wide range of reactions to their gender identities from medical staff. Negative experiences included refusal to provide transition-related care, invasive questioning, and other experiences of discrimination. Even after receiving prescriptions, some participants had similar experiences when trying to get hormone injections. Nevertheless, some transmasculine people had to stay with unfriendly or low-quality health care providers because they lacked other options.  

“After that I went to an endocrinologist. I chatted to him online only. He said, ‘Do not do all this. Your family will throw you out of the house. You are not doing good’. Being an endocrinologist, he knew that these things [transitioning] can be done but still he told me that I should not do it.” (23, Panchkula) 

“When I was going for the injection, they asked a lot of questions like ‘Why do you take it?’ When I told them that I was changing gender, some people’s faces would be crooked.” (28, Mumbai) 

On the other hand, some participants had positive experiences when accessing care in both government and private hospitals, and felt that their gender identities and transition-related needs were respected. 

 “Their reaction was very good. They listened to me. I said exactly what I wanted. If I wanted to have top surgery, I did what I expected, and they did it. I went to the surgeon, and they included a plastic surgeon in the team, and then they did the surgery. Their response was good.” (24, Pune) 

Overcoming diagnostic barriers

The path to gender-affirming hormone therapy or surgery generally begins with acquiring a referral letter from one or more psychiatrists or psychologists, including a diagnosis of gender dysphoria or incongruence (sometimes referred to by the obsolete abbreviation “GID”).   

During this process, some participants felt that their psychiatrist or psychologist was “in charge” of their access to transition-related care and were intimidated by the amount of power that psychiatrists had over their access to transition care. One participant even opted to travel to the United States to obtain documentation needed to pursue his transition. In response, transmasculine community members were sometimes cautious about revealing any doubts or mental health challenges they were facing, as they worried that the doctor might refuse to provide a letter.  

“My friends told me that whatever questions asked by the doctor, ‘Speak positively: if you feel disturbed or negative, or uncomfortable, the doctor will cancel your GID [diagnosis/certificate].’ I answered positively and gave the test. After the test, they gave me a GID [certificate]. In one day, I took two GIDs [certificates] because I had to do a small surgery also. One or two GID is compulsory, so I took two.” (26, Kalyan) 

At the time of data collection, the 7th version of the World Professional Association for Transgender Health Standards of Care recommended one assessment by a mental health provider before beginning hormone therapy and two assessments before genital surgery. However, the Association for Transgender Health in India Standards of Care (2021) recommends two assessments with diagnoses prior to hormone therapy. These guidelines may influence some of the practices our participants described (e.g., needing to obtain two referral letters before starting hormones) although we know that not all hospitals in India follow either set of guidelines.  

“They asked me a question and they thought it was right and then they gave me a GID [certificate]. Two GIDs are necessary, so I went to another doctor. They also asked me questions and gave me GID. My experience here was great.” (26, Navi Mumbai) 

Achieving transition goals

After receiving the hormone therapy and/or surgery they needed, participants experienced reduced gender dysphoria and gained a sense of happiness and peace. However, some participants were dissatisfied with their surgical results. This dissatisfaction enforces the cyclical nature of gender-affirming care, as patients may continue to access care until their transition goals are reached.  

“Felt great. It felt great when I saw myself. Looking at it, it seemed that now I was changing. I am getting or am going to get what I want in life.” (24, Delhi) 

“The surgery is done, I am 70% happy with that surgery, but I got at least a flat chest, I was very happy about that. And it increased my confidence very much.” (43, Mumbai) 

General Health Care 
As with gender-affirming care, participants had a range of negative and positive experiences when seeking general health care. Negative experiences with general physicians included unnecessary invasive examinations, being refused care, and hesitancy to disclose their gender identity. In contrast, some participants noted positive reactions after they explained their trans identity.  
 
“Once I went to a doctor because I had a back problem. At that time, he did an X-ray examination. At that time, I told him that I had a transition and an operation. I told them the details. He then examined me physically without my permission, and he also examined my private parts, which was not necessary.” (24, Pune) 
“Because my name was a female name and my appearance was as a boy. So, I explained to him about myself, and he reacted positively. He said I knew there was something different. My experience with that doctor was very good.” (30, Delhi) 

Conclusion and Recommendations

Our Health Matters participants often faced barriers to gender-affirming health care, including a lack of publicly accessible information, costly or low-quality care, discrimination, and excessive screening processes before providing the “GID” certificate. However, we also heard about how transmasculine people supported each other to find suitable doctors, and how they were persistent in overcoming obstacles to hormones and surgery.  

Based on our findings, we recommend the following changes to minimize the challenges faced by transmasculine persons accessing gender-affirming health care in India. These actions can be taken by central government ministries (e.g., Ministry of Social Justice and Empowerment, National Health Authority), state governments, international organizations (e.g., United Nations Development Programme), medical associations, and trans networks.   

Improving Access to Information 

  • Publish multilingual information about trans-affirming and transition health care, including a database of providers (e.g., online databases managed by community-based organizations or government agencies in different states of India). 
  • Provide funding to community-based organizations to strengthen and formalize existing referral and support networks.  

Increasing Affordability and Quality of Care 

  • Increase coverage of transgender health in medical curricula. See the TransCare: Med-Ed project for additional information.  
  • Offer training on trans-affirming care for existing medical staff.  
  • Fully implement the recently-announced initiatives (i.e., through the Ayushman Bharat scheme) to increase access to gender-affirming care through public hospitals, while addressing barriers for transmasculine people who do not want an ID card that labels them as transgender, or who face challenges trying to apply for one.   
  • Increase skills-building training opportunities for doctors who may prescribe hormones for transmasculine patients, as well as surgeons who may perform gender-affirming surgeries, particularly those who will be listed under the Ayushman Bharat scheme . 
  • Develop trans-affirmative clinics for hormone prescriptions and injections (e.g., drop-in sessions with medical staff at community organizations and government hospitals). It may also be helpful to offer other health care services at these clinics (e.g., sexual and reproductive care).  

Overcoming Diagnostic Barriers 

  • Revise clinical guidelines and practices to follow the 8th edition of the World Professional Association for Transgender Health Standards of Care, which focus on the patient’s ability to give informed consent, rather than on diagnosing gender dysphoria. If a referral letter (e.g., from a psychiatrist) is needed, only one such assessment should be required. Further, the placement of ‘Gender incongruence’ in the Sexual Health chapter of WHO’s International Classification of Diseases-11th edition (ICD-11) seems to indicate that diagnosis of ‘Gender incongruence’ need not necessarily be made by psychiatrists.  
  • Improved communication between medical organizations, doctors, and community members to prevent patients from pursuing multiple assessments or other services that are not needed.  

References 

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